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Rosland AM, Wong ES, Zulman D, Piegari R, Prenovost K, Fihn SD, Nelson KM. Higher Level of Patient-Centered Medical Home Implementation Associated with Improvements in Clinical Quality of Care in the Nation-Wide VHA PACT Initiative. Poster session presented at: Society of General Internal Medicine Annual Meeting; 2015 Apr 22; Toronto, Canada.
Abstract: BACKGROUND: In 2010, the Veterans Health Administration (VHA) began to establish patient-centered medical homes (PCMH) at all primary care (PC) clinics nationwide as part of the Patient Aligned Care Teams (PACT) initiative. PACT focuses on whole-clinic improvements in patient-centered care delivery, such as increased continuity and access and multi-disciplinary team-based care. PACT does not explicitly focus on care for specific medical conditions or patient populations. However, effective implementation of PCMH may have beneficial effects on care for chronic illness. This study examined whether extent of PACT implementation at individual VHA PC clinics by 2012 was associated with changes in chronic illness care between 2009 (pre-PACT) and 2013. METHODS: Pre-post observational study of VHA's 955 PC clinics (serving > 5 million patients). Using multivariate linear regression, we examined the association between clinics' PACT implementation and clinic-level change in 15 individual clinical quality indicators (CQI) for patients with diabetes (DM), hypertension (HTN), ischemic heart disease (IHD), and heart failure (HF). CQI were collected by VHA's External Peer Review Program, in which external contractors manually abstract electronic health records to assess clinical performance using standardized criteria. Each indicator is expressed as the % of a clinic's qualifying patients who received guideline adherent care. PACT implementation was measured using the previously developed PI2 score, an 53 variable index representing 8 PCMH domains, ranging from -8 (least extensive implementation) to +8 (most extensive). All models were adjusted for clinics' baseline value of the CQI measure, community vs. hospital-based clinic, rural vs. urban location, and area unemployment levels. Results are reported as model-based predictions for 2009-2013 change in proportion of patients receiving guideline adherent care for clinics with the least PACT implementation (PI2 < -4) vs. those with the most (PI2 > +4). RESULTS: Overall, clinical quality was high. However, more extensive PACT implementation was significantly associated with larger improvements in 5 quality measures at p < 0.05 and in 2 measures at p < 0.06. Specifically, compared to clinics with the least PACT implementation, clinics with the most PACT implementation had significantly greater improvements in: annual LDL measurement in IHD (2009-13 predicted change +2.4% vs. 0%, p < 0.01), LDL < 100 in IHD (+7.8% vs. +2.7%, p < 0.01) and DM (+3.1% vs. +0.09%, p = 0.06), ACE inhibitor or ARB prescription for recent IHD with EF < 40% (+0.03% vs. -0.02%, p < 0.01), blood pressure < 160/100 in HTN (+0.8% vs. -0.9%, p < 0.001) and DM (+0.2% vs. -1.1%, p = 0.03), and annual HbA1c measurement in DM (+1.3% vs. +0.5%, p = 0.06). Measures for which change over time was unassociated with PI2 score were: aspirin prescription in CVD or DM; HbA1c < 9 in DM; regular foot, retinal or renal function checks in DM; and HF with EF < 40% with ACE inhibitor/ARB prescription. CONCLUSIONS: Over the period of initial PACT implementation, clinics with PACT most extensively in place by 2012 had significantly larger improvements in almost half of the chronic disease process and outcome quality measures examined. This study suggests that focusing resources on PCMH-aligned changes in care delivery across all patients may result in downstream improvements in quality of care and clinical outcomes for patients with specific chronic diseases.

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